2015

Acupuncture ~ Health History

Patient Name: _______________________________________

Age: ______________

Date: _________________

Date of Birth: ____________ Date of last physical exam: ___________

What is your primary reason for this visit? ________________________________________________________

SYMPTOMS: place a check mark by all symptoms you have today, or have had in the last year.
GENERAL
__Chills
__Depression
__Dizziness
__Fainting
__Fever
__Forgetfulness
__Headache
__Sleeplessness
__Weight loss
__Nervousness
__Numbness
__Sweating

GASTROINTESTINAL

__Poor appetite
__Bloating
__Bowel Changes
__Constipation
__Diarrhea
__Excessive hunger
__Excessive thirst
__Gas
__Hemorrhoids
__Indigestion
__Nausea
__Rectal bleeding
__Stomach pain
__Vomiting
MUSCLE/JOINT/BONE __Vomiting blood
Pain/Weak/Numb in:
__Neck __Shoulders CARDIOVASCULAR
__Arms __Hands
__Chest pain
__Back __Hips
__High blood pressure
__Legs __Knees
__Irregular heart beat
__Feet __Other
__Low blood pressure
__Poor circulation
GENITO-URINARY
__Rapid heartbeat
__Blood in urine
__Swollen ankles
__Frequent urination
__Varicose veins
__Bladder control
__Painful urination

EYE/EAR/NOSE/THROAT
__Bleeding gums
__Blurred vision
__Crossed eyes
__Difficulty swallowing
__Double vision
__Earache
__Ear discharge
__Hay fever
__Hoarseness
__Hearing loss
__Nose bleeds
__Persistent cough
__Ringing in ears
__Sinus problems
__Visual flashes of light
__Visual halos
SKIN
__Bruise easily
__Hives
__Itching
__Change in moles
__Rash
__Scars
__Sores that wont heal

MEN ONLY
__Breast lump
__Erection difficulties
__Lump in testicles
__Penis discharge
__Sore on penis
__Other _______________
WOMEN ONLY
__Abnormal pap smear
__Bleeding between periods
__Breast lump
__Extreme menstrual pain
__Hot flashes
__Nipple discharge
__Painful intercourse
__Vaginal discharge
__Other __________________
Date of last menstrual period
__________________________
Date of last pap smear
__________________________
Date of last mammogram
__________________________
Are you pregnant? _________
Number of children ________

CONDITIONS: place a check mark next to all conditions you have now or have had in the past
__AIDS
__Alcoholism
__Anemia
__Anorexia
__Appendicitis
__Arthritis
__Asthma
__Bleeding disorder
__Breast lump
__Bronchitis
__Bulimia
__Cancer
__Cataracts

__Chemical Dependency
__Chicken pox
__Diabetes
__Emphysema
__Epilepsy
__Glaucoma
__Goiter
__Gonorrhea
__Gout
__Heart Disease
__Hepatitis
__Hernia
__Herpes

__High Cholesterol
__HIV positive
__Kidney disease
__Liver disease
__Measles
__Migraine headache
__Miscarriage
__Mononucleosis
__Multiple sclerosis
__Mumps
__Pacemaker
__Pneumonia
__Polio

MEDICATIONS AND ALLERGIES: list all below or attach a separate list

Current Medications:
Allergies:
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__Prostate problems
__Psychiatric care
__Rheumatic fever
__Scarlet fever
__Stroke
__Suicide attempt
__Thyroid problems
__Tonsillitis
__Tuberculosis
__Typhoid fever
__Ulcers
__Vaginal infections
__Venereal disease

FAMILY HISTORY: Fill in health information about family members related by blood line
Relation

Age

Healthy?

Age at Death

Cause of Death

Father
Mother
Brothers

Sisters

Check each condition a relative has experienced:

Disease
Relationship to you
Arthritis/Gout
Asthma/Hay fever
Cancer
Chemical dependence
Diabetes
Heart disease/Stroke
High blood pressure
Kidney disease
Tuberculosis
Other

HOSPITALIZATIONS:
Year

Hospital

Reason for treatment and outcome

Have you ever had a blood transfusion? __No

Serious Illness/Injury

Pregnancy History:
Year
Gender

Complications

__Yes (if yes, please provide approximate dates) _____________

Date

Outcome

HEALTH HABITS: place a check mark next to any that apply and describe how much you use
__Caffeine _____________________________

__Tobacco ________________________________________

__Street drugs _________________________

__Other ___________________________________________

OCCUPATIONAL CONCERNS: place a check mark if you are exposed to the following
__ Stress

__Hazardous materials/waste

__Heavy lifting

__Other

What is your occupation? ______________________________________________________________________________

__________________________________________
Signature of Patient

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____________________________________
Date

If you are having pain, please describe the date and the event or events which led to your present pain:
Date
__________ Accident

Description
_____________________________________________

__________ Injury

_____________________________________________

__________ Following surgery

_____________________________________________

__________ Cancer

_____________________________________________

__________ Other disease

_____________________________________________

__________ No obvious cause

_____________________________________________

Using the figure provided, please indicate the location and type of pain you experience:
AAA = Ache

NNN = Numb

What makes your pain better?

What makes your pain worse?

Does the pain interrupt your sleep?

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OOO = Pins/Needles

XXX = burning

/// = stabbing

2015

Applied Pain Institute LLC

1015 S. Mercer Avenue
Bloomington, IL 61701

Patient Registration Information:

Patient Name: _________________________________

Date: _______________________

Address: _______________________________________________________________________________
City: _________________________________________
Birth date: ____________________________________
Married _______

Single _______

State/Zip: ____________________
Age: _______

Widowed _______

Gender: M F
(circle)

Home Phone: __________________ Cell Phone: __________________ Work Phone: ______________

NOTICE REGARDING INSURANCE COVERAGE FOR ACUPUNCTURE

Effective January 1, 2011
Payment is due in full at the time of service.
In order for our billing staff to submit your claim to insurance, you must contact your insurance company
to request a statement of coverage specific to the conditions for which you receive acupuncture.
If your policy does not cover acupuncture for your condition, we cannot submit your bills.
If we are not in network with your insurance, regardless of whether acupuncture is covered, we cannot
submit your bills. Any discounts or write-offs are the patients expense in out of network scenarios.
If you have a Medical Expense Reimbursement plan, please pay BEFORE your treatment and we will
have a paid receipt ready for you when your treatment is complete.
If you have a CIGNA plan that allows acupuncture you are responsible for having your primary care
obtain preauthorization for your treatment. If your primary has question he or she is welcome to call for
information, but we cannot act on his or her behalf.
Billing Exceptions:

Blue Cross Blue Shield due to contractual obligations

Workers Compensation due to required pre-authorizations

Medicare as primary insurance ONLY when the denial is needed for secondary insurance to pay.

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Primary Insurance:
Insureds Name: __________________________________________________________________________
(last)
(first)
(middle initial)
Relationship to patient _________________________________ Insureds Birth date: _________________
Address (if different from patient): ___________________________________(phone)_________________
City:____________________________________

State/Zip: ____________________________

Insureds Employer: __________________________________Occupation: _________________________

Business Address: ___________________________________________(Phone)______________________
Insurance Company: ______________________________________________________________________
Secondary Insurance:
Insureds Name: __________________________________________________________________________
(last)
(first)
(middle initial)
Relationship to Patient: ______________________________________(Birth date)____________________
Address (if different from patient) ____________________________________________________________
City: ____________________________________

State/Zip: ____________________________

Insureds Employer: __________________________________Occupation: _________________________

Business Address: ___________________________________________(Phone)______________________
Insurance Company: ______________________________________________________________________

Please provide your photo identification.

We will only need copies of your insurance cards if you qualify for
insurance billing (see above).

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Workers Compensation:
Please ask the front desk staff for our Workers Compensation form. Complete all sections.
You must provide all claim information before being seen.
We must receive written authorization before providing treatment. We may require your help or
the help of your attorney to obtain this authorization.

Auto Accidents and Personal Liability Claims:

All Auto Accident and Personal Liability Claims

are subject to Lien for Payment.
You must provide all claim information before being seen.
Date of accident/injury _____________________
Select type of claim:
___ Non-auto (personal liability) claim

___ Auto (At-Fault Driver)

___ Auto (Other driver At-Fault)

For Auto Claims:

Your Auto Insurance Company _____________________________________________________
Your Claim number __________________________
Name of Your Insurance Companys Claim Adjustor___________________________________
Other Drivers Name ______________________________________________________________
Other Drivers Auto Insurance Company______________________________________________
Name of Other Drivers Claim Adjustor________________________________________________
Name of Attorney ___________________________________ Attorney ph # ________________
For Non-auto Claims:
Name of Insurance Company __________________________________________________________
Name/ph # of Responsible Party ________________________________________________________
Name of Attorney ______________________________ Attorney ph # _________________________
For all Workers Compensation, Auto Accident and Personal Liability Claims:
You are required to provide:
1. Regular (commercial, group or individual) health insurance cards
2. photo identification

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2015

Applied Pain Institute, LLC

1015 S. Mercer Avenue
Bloomington, IL 61701
Financial Agreement / Assignment of Benefits / Release of Records

Forms:
There is a $25.00 fee for completing each of the following forms:
Disability Insurance ~ Leave of Absence ~ Family Medical Leave Act (FMLA)
This fee is due when the form is submitted forms are not completed until payment is received.
This office does not complete Certification for Permanent Disability or Financial Hardship forms. Please direct
these forms to your primary care physician.
Late Cancellation/Missed Appointments:
Because late cancellations and missed appointments impact
everyone a $25.00 fee will be charged for appointments that are missed without 24 hours notice. This fee cannot
be billed to insurance and therefore, is the responsibility of the patient. This fee is subject to collections if not paid
within 60 days.
Non-sufficient funds/Returned Checks: Checks returned for insufficient funds will result in a $25.00 service fee in
addition to the original billed amount. Please make payment arrangements with our billing staff to prevent
incurring additional fees.
Collections and Interest Owed: If your outstanding balance is more than you can afford within the first 60 days
please make payment arrangements with our billing staff before you incur additional fees and interest owed, as
well as risking damage to your credit record.
Every effort is made to bill insurance accurately and in accordance with insurance timely filing rules; however, it is
ultimately the patients responsibility to pay for services rendered. Additionally, it is the patients responsibility to
notify this office of any change in insurance coverage. I understand that this office bills for reimbursement from my
insurer or other third party payer as a courtesy. Failure on the part of the insurer to make payment shall not relieve
me of my obligation to pay for services rendered. Once insurance makes a determination, all outstanding balances
are patient responsibility to the extent allowed by law and by contractual agreements with the insuring entity. This
balance is due within 60 days. Account balances that are 60 days past due may bear interest on the unpaid
amount up to the maximum allowed by law and will be sent to collections. Collection fees and attorney fees are in
addition to the outstanding balance and are the responsibility of the patient. I hereby waive all claims of
exemption. Should the account be referred to an attorney, I shall pay reasonable attorney and associated
collection expenses regardless of whether suit is filed.
Insurance Assignment of Benefits and Release of Medical Information: I assign all insurance benefits (Medicare,
Medicaid, group or private commercial insurance, Workers Compensation) to be paid directly to Applied Pain
Institute, LLC for services rendered. A photocopy of this agreement shall be valid as the original.
I authorize the use of my signature below for all insurance submissions. I authorize Applied Pain Institute, LLC
(physicians, staff, other HIPAA authorized agents) to disclose my protected health information (medical and
financial records) for the purposes of determining insurance benefit eligibility and preauthorization/
predetermination, obtaining benefit payment, and/or discussing disputed payments related to services rendered. I
further agree to allow my protected health information to be released to (a) any affiliate and its employees and
agents for continuation of care; (b) any person or entity responsible for all or part of continuation of care rendered
at a hospital or ambulatory surgical center; (c) any person or entity to whom I have been referred for continuing
care; (d) any physician treating, consulting, or otherwise performing services for me, including his or her
employees or agents; (e) the Health Care Financing Administration, any government or accrediting agency, or
their agents or employees.
I understand I am financially responsible for all charges regardless of insurance payment (co-pay, deductible,
excluded for any reason, or otherwise denied to the extent not expressly prohibited by law or by the contract
between the provider and my third party payer).
Your signature below indicates that you have read and understand these policies.
______________________________________________
Signature of patient/authorized representative

___________________________
Date

FINANCIAL AGREEMENT READ BEFORE SIGNING

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Applied Pain Institute, LLC

1015 S Mercer Avenue
Bloomington, IL 61701
Phone: 309-662-0088

Fax: 309-662-0089

HIPAA Acknowledgement and Message Permission

I acknowledge I have been offered a copy of the HIPPA Privacy Notice from Applied Pain Institute, LLC.
Our staff will attempt to speak directly with you about your healthcare needs; however, if we are unable
to reach you, your signature below indicates you understand and agree that we may leave a general
voice message for you at the phone numbers which you have provided to us. Additionally, with your
signed permission below, we may communicate with your family members or other designated persons
about your appointments and your health care issues.
Initial here to grant permission for messages:

Yes ________ No __________

Initial here to grant permission for communication with others:

Yes ________ No __________

Please list the contact information for any designated persons

_________________________________________________________________________________________
Name
Relationship
Phone number

_________________________________________________________________________________________
Name
Relationship
Phone number

_______________________________________________
Print name of patient/authorized representative

___________________________
Date of Birth

______________________________________________
Signature of patient/authorized representative

___________________________
Date

If Personal Representatives signature appears above for either of these designations, please indicate
relationship to patient and provide a copy of legal authority to act on patients behalf.
_____________________________________________________________________________
Relationship (POAH, Guardian, Custodian, etc.)

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Applied Pain Institute, LLC

1015 S Mercer Avenue
Bloomington, IL 61701
Phone: 309-662-0088

Fax: 309-662-0089

Self-Referral Information

Effective August 23, 2004, a law (SB 2254) was signed into effect modifying the Acupuncture Practice
Act. The law states a physicians referral is no longer necessary in order to receive acupuncture
treatment. This law can be found in Public Act 93-999.
Acupuncture is an alternative treatment that should be used in conjunction with the care, diagnosis, and
treatment of a primary care physician or specialist. As a self-referring patient you are responsible for
seeking and maintaining proper care from a primary care physician.
If at any time Jiong Gu, licensed acupuncturist feels it is necessary for you to see your primary care
physician or a specialist he will advise you. At his discretion, he may choose to discontinue treatment
until you have sought the recommended care and have been advised to resume acupuncture.
Your signature below indicates you have read and understand the above information.

_______________________________________________
Print name of patient/authorized representative

______________________________________________

___________________________

Signature of patient/authorized representative

Date

If Personal Representatives signature appears above, please indicate relationship to patient and
provide a copy of legal authority to act on patients behalf.

_____________________________________________________________________________
Relationship (POAH, Guardian, Custodian, etc.)

01/2015 Rg

Applied Pain Institute, LLC

1015 S Mercer Avenue
Bloomington, IL 61701
Phone: 309-662-0088

Fax: 309-662-0089

Notifier(s): APPLIED PAIN INSTITUTE, LLC

Patient Name:

Medicare ID number:

ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN)

NOTE: If Medicare doesnt pay for items checked or listed in the box below, you may have to pay. Medicare does not
pay for everything, even some care that you or your health care provider have good reason to think you need.
We expect Medicare may not pay for the items listed or checked in the box below.

Listed or
Checked Items
Only:
Reason
Medicare
May Not Pay:

ACUPUNCTURE with or without electric

stimulation (CPT codes 97810 or 97813)
Non-covered

Estimated
Cost:
$70/SESSION
WHAT YOU NEED TO DO NOW:
Read this notice, so you can make an informed decision about your care.
Ask us any questions that you may have after you finish reading.
Choose an option below about whether to receive the checked items listed in the first box above.
Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but
Medicare cannot require us to do this.
Options:

Check only one box. We cannot choose a box for you.

OPTION 1. I want Acupuncture as listed above. You may ask to be paid now, but I also want Medicare
billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I
understand that if Medicare doesnt pay, I am responsible for payment, but I can appeal to Medicare by
following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you,
less co-pays or deductibles.
OPTION 2. I want Acupuncture as listed above, but do not bill Medicare. You may ask to be paid now as
I am responsible for payment. I cannot appeal if Medicare is not billed.
OPTION 3. I dont want Acupuncture as listed above. I understand with this choice I am not responsible
for payment, and I cannot appeal to see if Medicare would pay.

Additional Information:

This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or
Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).
Signing below means that you have received and understand this notice. You may also receive a copy if you wish.

Signature:

Date:
For all dates of service with acupuncture

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please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-R-131 (03/08)

0938-0566

01/2015 Rg

Form Approved OMB No.